We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

Business Retention Expansion COVID-19 Business and Human Impact Survey

Numbers are critically important to tell the collective story of the COVID-19 virus impact on our business community locally. Right now, everyone is acting on assumptions. Our numbers help detail the reality for decision makers.

As a business executive, we would very much appreciate your input. It will take about 10 minutes to complete the survey. Your responses are absolutely confidential. Responses will only be reported in aggregate.

The aggregate results of this survey will be used to inform local and state elected officials, government agencies, and others of the economic and human impact of the COVID-19 virus here. This survey is part of a national effort by local economic development organizations and chambers of commerce. It will be conducted several times as things are changing quickly.

If you ask for help at the end of the survey, members of the Montgomery County Action Council staff will reach out to you personally as soon as possible.

Thank you for your support!

1. What is the current operating status of your business? *

What is the current operating status of your business? *

((If Reopened)) What was the date of reopening?

Date __/__/__

((If open or reopen)) Current operating level

	a. What is your current on-site business operating level?
	c. What percentage of your supplies/services are you able to receive?
	d. What percentage of your goods or services are you able to ship/deliver?

((If Closed)) What was the date of closure?

__/__/__ Date

2. What was your current total employee count prior to COVID-19? *

	Full Time
	Part Time

3. Has your employee count changed due to COVID-19 specifically? *This question is required.

Has your employee count changed due to COVID-19 specifically? *

((If yes)) Workforce change

	New hires
	Furloughed
	Laid off
	Terminated

4. If employees are temporarily not reporting for work, what percentage will be paid during the work hiatus? *
*This question is required.

	Paid
	Unpaid
	Does Not Apply

5. FINANCE:

Has your company’s weekly revenue experienced an increase or decrease as a result of COVID-19? *

No Change

6. How many weeks of a business shutdown would you estimate your business could survive before closing? *

Number 0-52 Weeks

7. Have you contacted your bank about a bridge loan or other financing?

Yes
No
Unnecessary
Lenders are not responding

8. Have you applied for an US Small Business Administration Economic Injury Disaster Loan (EIDL)?

Space Cell	Yes	No	I’d like more information on these programs (contact info required)
Pending	Pending: Yes	Pending: No	Pending: I’d like more information on these programs (contact info required)
Successful	Successful: Yes	Successful: No	Successful: I’d like more information on these programs (contact info required)
Unsuccessful	Unsuccessful: Yes	Unsuccessful: No	Unsuccessful: I’d like more information on these programs (contact info required)
Do not qualify	Do not qualify: Yes	Do not qualify: No	Do not qualify: I’d like more information on these programs (contact info required)
I’d like more information on these programs	I’d like more information on these programs: Yes	I’d like more information on these programs: No	I’d like more information on these programs: I’d like more information on these programs (contact info required)

9. Have you applied for the Payroll Protection Program?

Have you applied for the Payroll Protection Program?

Space Cell	Yes	No	I’d like more information on these programs (contact info required)
Pending	Pending: Yes	Pending: No	Pending: I’d like more information on these programs (contact info required)
Successful	Successful: Yes	Successful: No	Successful: I’d like more information on these programs (contact info required)
Unsuccessful	Unsuccessful: Yes	Unsuccessful: No	Unsuccessful: I’d like more information on these programs (contact info required)
Do not qualify	Do not qualify: Yes	Do not qualify: No	Do not qualify: I’d like more information on these programs (contact info required)
I'd like more information on these programs	I'd like more information on these programs: Yes	I'd like more information on these programs: No	I'd like more information on these programs: I’d like more information on these programs (contact info required)

((If Yes, Successful))

	Amount of PPP Grant
	Number of employees retained?
	Number of employees rehired?

10. What business supports would you think beneficial as we navigate this global challenge?

11. Respondent Information | All responses will be held in confidence |

Name

Full Name

Business Name

Business Address *This question is required.

	Street Address
	City
	County
	State
	Zip Code

Email Address

Phone number

Primary Phone Number:

12. Name of your company’s COVID-19 Customer Response Coordinator:

Same Contact as above

Full Name

Title

Phone number

13. * Which one of the following best describes your organization’s primary industry? (Select one only.)